AD/HD and Enuresis (Bedwetting)

Carol Watkins, M.D.

Enuresis (bedwetting) and Attention Deficit Hyperactivity Disorder (AD/HD or ADD) are both common conditions that can affect children and adolescents. Although there is no evidence that either one causes the other, children with AD/HD appear to have a higher incidence of enuresis. The child with AD/HD may feel different and unaccepted. Enuresis might exacerbate these feelings. There are several medically accepted treatments for enuresis. Some of them require impulse control and cooperation. Might this be more difficult for individuals with AD/HD? Individuals with AD/HD may be taking medications for the condition. How might these medications affect their enuresis? 

We all wet the bed at some point in our lives.  When a baby’s bladder fills to a certain point, the bladder muscles contract, and the baby urinates. Over time, the young child’s nervous system matures. The feedback circuits between the brain and the bladder enable the child to realize when his or her bladder is full. The child becomes physically able to delay urination until he or she decides that it is the appropriate time and place to void. Different children develop the neurological and emotional capacity to control their bladders at different ages. In many cases, children learn to control their bladders during the day before they master nighttime dryness. Occasional episodes of daytime or nighttime bladder accidents after five may be a normal part of growing up. . However, if a child continues to have regular trouble controlling his bladder after age five, he meets the criteria for enuresis.  Bedwetting (nocturnal enuresis) usually does not occur while the child is dreaming. It is more likely to happen during the deeper phases of sleep.

  • Primary enuresis refers to wetting in a person who has never been dry for at least 6 months.
  • Secondary enuresis refers to wetting that begins after at least 6 months of dryness.
  • Nocturnal enuresis refers to wetting that usually occurs during sleep (nighttime incontinence).
  • Diurnal enuresis refers to wetting when awake (daytime incontinence).

How common is bedwetting? The reported incidence varies depending on the study. Children do not like to admit to this problem. Thus the actual incidence may actually be higher than some estimates.  At age five the incidence is between 5-20%. It is much more frequent in boys than in girls. The incidence drops significantly with age. A general rule of thumb is that about 15% of children achieve nighttime dryness each year after age 5.  At age 5, enuresis affects 7% of boys and 3% of girls. By age 10, it affects 3% of boys and 2% of girls. About 1% of adolescents still experience enuresis.  That 1% may not sound like much, but it translates into a large number of adolescents and young adults with an embarrassing—sometimes-humiliating—problem. What causes enuresis? We do not know an exact cause of nighttime enuresis.   

  • Most children with enuresis seem to be normal, physically, intellectually and emotionally. Enuresis is probably associated with a combination of factors including heredity, slower neurological maturation, small bladder capacity, a tendency to produce too much urine at night, and the inability to recognize a full bladder while asleep. The child who is a deep sleeper may have more difficulty waking up when his bladder is full.
  • Sometimes enuresis may be due to anxiety, a change in the home situation (such as the birth of a sibling) or an emotional trauma. We particularly look for emotional factors in children who were previously dry and start to wet again. A child with shaky bladder control may be more likely to revert to wetting when under stress.
  • A small percentage of children have specific physical causes for their enuresis. Depending on the type of physical difficulty, the child might never have been dry (primary enuresis) or may have gone back to enuresis after a period of dryness (secondary enuresis) Physical problems include diabetes mellitus, lower spinal cord problems, congenital malformations in the genitourinary tract and urinary tract infections. Obstructive sleep apnea, sometimes caused when a child has enlarged tonsils or adenoids, can also be associated with enuresis. 

Treatment of enuresis: If the enuresis is related to a specific physical or emotional issue, the causative factor must be addressed. For the majority of children, there is not specific cause. It is often best to counsel the families of young children to wait and see whether the child becomes dry within the next year or two. Parents should not be harsh or judgmental. Sometimes it is the emotional reaction of the parent that causes the psychological hurt, more than the bedwetting itself. The child is often the best one to determine whether the bedwetting is a problem. Does the bedwetting bother him? Does it interfere with sleepovers or camping trips? The incidence of enuresis declines by about 15% per year after age five. Bladder capacity increases, an overactive bladder may normalize, the child learns to recognize the signal that it is time to void, and stressful events may fade.  

However, some children do require extra intervention for their bedwetting. Initial interventions may include:

  • Behavior Modification: The child learns to take responsibility for his bed-wetting. Encouraging and praising the child for staying dry instead of punishing when the child wets. Reminding the child to urinate before going to bed, if he or she feels the need. Limiting liquid intake at least two hours before bedtime. When he wets the bed, he is responsible for changing the sheets in the morning. He learns to wake up regularly at night to void. Bedwetting alarms are often useful. These devices are available for $50 -$100 in specialty catalogs, some pharmacies and medical supply sources. A moisture-sensing device is attached to the pajamas or is placed under the sheet. When the child urinates at night, the sensor sets off a buzzer and or a light alarm. Some children who wet the bed are especially deep sleepers. In these cases, it may be necessary for someone else to wake the child when the alarm sounds. Ideally the child eventually becomes conditioned to wake up when his bladder is full. 
  • Hypnosis: Some practitioners have had success using hypnosis to help children cooperate with behavior modification or even to become dry by themselves. 
  • Psychotherapy: This is used when the child is showing severe anxiety in relation to his bedwetting and this anxiety is interfering with teaching him to become dry. It is also useful if the enuresis is associates with external stress or trauma.
  • Evaluation for allergies: In rare cases, food or other allergies may be related to enuresis.
  • Medication: There are two main medication approaches. DDAVP (desmopressin acetate) is a safe and effective long-term treatment for patients with nocturnal enuresis. More than half of the children treated this way show a positive response. DDAVP is a compound similar to the hormone that regulates urine production. It is sprayed into the child’s nose at night. It decreases the production of urine for several hours. Children who do not respond to DDAVP may respond to a tricyclic antidepressant, imipramine (Brand name Tofranil.) Some clinicians have successfully used other, related tricyclics. These medications are sometimes also used for treatment of depression, AD/HD and narcolepsy (sleep attacks). Sometimes a parent is confused when their doctor suggests imipramine, “My child is not depressed!” For children, the FDA approves imipramine only for enuresis.  Tricyclics can sometimes be associated with changes in heart rhythm. Ask your doctor whether he or she feels that an EKG or other testing is indicated. In my experience, children who are especially deep sleepers, and who do not respond to other treatments, may respond well to the tricyclics. Unfortunately, when the medication is stopped, some children relapse. Some children take medication only when they are in special situations when bedwetting would be especially embarrassing—sleepovers or camping trips. Other children take the medication every night.

Like enuresis, AD/HD is also a common childhood condition. . Individuals with inattentive ADHD have difficulty paying attention and staying organized. Individuals with impulsive or combined ADHD have difficulty with attention and organization but also are overly active and impulsive ADHD affects 3-5% of school-aged children.  Although most children with enuresis experience remission of their enuresis by age 18, a higher percentage of individuals with AD/HD continue to experience inattention and impulsivity well into adulthood. For years, clinicians have anecdotally noted an increased incidence of enuresis in children with AD/HD.  Others have observed that their patients with enuresis have an increased incidence of AD/HD. Because both conditions are fairly common, it would be important to have more systematic studies that looked at the relationship between enuresis and AD/HD.

An article in the Southern Medical Journal published in 1997compared a fairly large group of 6-year-old children with AD/HD to a non-AD/HD control group selected from a pediatric clinic population.  They found that the 6-year-olds with AD/HD had 2.7 times higher incidence of enuresis and a 4.5 times higher incidence of diurnal (daytime) enuresis as compared to a control group Other authors have cited higher rates of enuresis in children with ADHD. However, these studies did not have control groups or were not selected randomly.

Sometimes enuresis may be more upsetting for a child with AD/HD.  A non-AD/HD child, who is successful in most spheres, may be able to accept his bedwetting more easily. Later, such a child may find it easier to cooperate with behavioral interventions. However the child with ADHD already feels different from his peers. His disorganization and impulsivity may lead to peer rejection and shame. Such a child may cover his shame with a false appearance of bravado. And although he may be more ashamed of his bedwetting, his inattention and disorganization may make it more difficult for him to cooperate with some behavioral treatments. Individuals with AD/HD are more likely to have sleep problems. Some of them sleep deeply and have difficulty waking up to go to the bathroom when their bladder is full.

Treating the child with both AD/HD and enuresis: This child should have a complete physical exam. It is important to always ask an individual with AD/HD about current and past bedwetting problems. Don’t neglect to ask adolescents about this too. They will rarely volunteer this information on their own. Ask what they and their parents have tried in the past. Some children and teens with AD/HD are veterans of many types of therapy. They may already expect the treatment to fail. The behavioral techniques listed earlier in the article are still useful for these children and teens. Since these children have often experienced teasing and criticism, one should be especially careful to avoid punitive behavioral techniques. One may have to modify behavioral interventions to accommodate the child’s shorter attention span. You may need to prioritize symptoms. If the child has a myriad of behavior difficulties, the family cannot address all of them at once. Which ones are the most important to the child and the parent? Some children and families opt to wait a while longer before starting behavioral or medical interventions.  When  the family decides that this is the time to treat the enuresis, they may have to back off with some of their other behavioral goals to avoid being overwhelmed. The child and family should be made aware that there are several ways to treat the enuresis. If one does not work, you are not a failure. You still have plan B, plan C, etc.

Medication for children with both AD/HD and enuresis. Some children with AD/HD may also have other psychiatric disorders and may be on several medications. A few of these medications might exacerbate the enuresis.  It is important to consider all medications and all medical conditions before proceeding with treatment.   DDAVP help the enuresis of some children and teens with AD/HD.. In other cases, one may want to consider one of the tricyclic antidepressants for the enuresis. This class of medication seems to work well with some of the “deep sleeper” kids.. You may be able to treat both the AD/HD and the enuresis with one medication. Several studies have shown that the tricyclics by themselves are an effective medical treatment for AD/HD in children and adults  In some cases, one can combine stimulants and tricyclics. Such cases may require more frequent medical monitoring.

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Northern County Psychiatric Associates 

Our practice has experience in the treatment of Attention Deficit disorder (ADD or ADHD), Depression, Separation Anxiety Disorder, Obsessive-Compulsive Disorder, and other psychiatric conditions. We are located in Northern Baltimore County and serve the Baltimore County, Carroll County and Harford County areas in Maryland. Since we are near the Pennsylvania border, we also serve the York County area.   Our services include psychotherapy, psychiatric evaluations, medication management, and family therapy. We treat children, adults, and the elderly.

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Carol Watkins, MD
Northern County Psychiatric Associates
Lutherville and Monkton
Baltimore County, Maryland
Phone: 410-329-2028
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